Therapeutic Guidelines Pain and Analgesia

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Welcome to this Australian Prescriber Podcast. I'm Dr Justin Coleman, a GP on the Tiwi Islands in the Northern territory, in the middle of a glorious dry season where you're wearing a thick jacket and I'm wearing a t-shirt. And today I'm speaking about pain and analgesia. About alleviating suffering without causing more suffering. And with me on this ambitious project is Dr Chris Hayes who's Director of the Hunter Integrated Pain Service, and Chris is a specialist physician in pain. Chris, welcome to our warm winter edition of this podcast.

Thank you Justin. I'm sitting in my coat in the office in the cool of Newcastle, on the east coast Australia. So feeling a little envious about your Tiwi Island geography.

Good. I might even consider turning the air con off at some point. So we're talking about eTG Pain and analgesia. And now, astute listeners may note that the guide used to be called Analgesia alone, but now is Pain and Analgesia. And I wonder if that reflects the fact, Chris, that analgesics are a class of medication. Whereas, as every struggling GP and pharmacist knows, managing pain, purely with painkillers, can sometimes be an unrewarding task. So I guess the pain is designed to broaden the scope of the guidelines?

That is exactly right. Readers of the updated guideline will note that there has been substantial revision. And we were particularly keen to pick up on that breadth, the more holistical multidimensional aspect, noting as you say, that often the analgesic medications are perhaps disappointing in some situations of pain and particularly chronic rather than acute pain.

Certainly when discussing pain, I'm always tempted to jump right to the strong stuff, the meaty dilemma of opioids, because often patients tend to expect that we do that. But I am going to restrain myself and take it more slowly in a logical order. So I thought we would start with that multidimensional aspect you're talking about, the biopsychosocial factors.

And I think your perspective is good Justin. Often, we are needing to slow the process down as we're thinking through these issues medically, and also as we're dealing with patients. They may, as you say, want to cut to what they see as the core element and get onto some strong medication. Our task as clinicians is to slow the process down, at least to some extent I think, and to make sure that we assess broadly, recognising that pain, whether it is acute or chronic, is multidimensional.

So we do need to think even in the acute injury perspective about the surrounding environmental, social, cultural, psychological perspectives, the biopsychosocial approach as it is called. Or by some, the sociopsychobiomedical approach. But whichever way, we're looking at going beyond just the simple structural medical aspects and looking at what's happening in the person's mind and what's happening in the broader social construct around them.

I see there is a table which summarises how to take a pain history, which has a lot of those questions as well. So let's look at the person walking into our office, who does have pain of some sort. And particularly here, I'm talking about sort of ongoing pain rather than pain that started yesterday. How do we assess that person?

I think it is good to look for any underlying harmful conditions at first pass. This is, I think, largely what patients expect. And I think GPs broadly do a very nice job of this. So this is the search for the broken bone, or the infection, the underlying cancer etc., the traditional red flag conditions. So that that's part of it. But I guess if the patient has had pain for some time, the likelihood is that they probably won't have any of those red flags.

And then I think it's good to be fairly strong and not too slow in moving to look at the broader social dimension. So to start to think about what is happening psychologically and socially, for that person – what else was happening when the pain came on or when this current flare-up started. Just that sense of what else is happening in your life at the moment is a nice entree question into some of these broader dimensions, as well as to broaden the medical history as well.

What are the co- or the multi-morbidities? What are the different medications that the patient may be on? But certainly to explore and link the psychosocial aspects, I think, is key. And to acknowledge early that the reason why you're asking about some of these psychological and social aspects is because they may well be contributing to the pain and they may well be targets for therapeutic intervention.

The majority of patients I've found enjoy the attention paid to them – someone caring, asking about all those things. Do you get many people attending the pain service who get a bit annoyed and frustrated by you sort of going what they see is off track?

This is a constant challenge. And I think it's fascinating in the interaction between the GP and the specialist pain service, I think, in terms of what the person's expectation is as they come into the specialist service. But in answer to your question, yes, we do see quite a few people who perceive that we are getting off track. ‘Are we suggesting that the pain is all in their head?’ they might challenge us with. ‘Really all I need is a rubber stamp for the opioids that I’m on.’ The GP just wants that, maybe their simplistic recounting of the situation, which may or may not be true.

Yeah. That's part of our challenge at the specialist service to welcome someone, to note and give space for complexity, and to boldly persist in asking these broader questions. And explain that this is very relevant as we formulate what's happening and as we make treatment recommendations. And to give a sense of hope that going broad isn't just a distraction, and us avoiding talking about the opioid issue. But to give that sense of hope that in that breadth of assessment, we will lead on to breadth of active treatment strategies and potentially reduction of their chronic pain. Maybe even resolution of their chronic pain in some situations.

Yeah. So starting with the end goal in mind is always good advice I think. Moving on to the actual types of pain, because there are various bodily systems. And then they're all modified by the brain itself, of course, as to how people experience pain. We have nociceptive pain and we have neuropathic pain, and we have something you just told me about 10 minutes before this podcast started, which is nociplastic pain.

Readers of the traditional pain textbooks would note that there have been the two types of pain described for some years now. The nociceptive equals tissue damage pain and the neuropathic equals nerve damage pain. But curiously, where I work in a chronic pain clinic, most patients that we see with long-term pain don't have an obvious nociceptive or tissue damage component, because the tissue injury has healed and a majority don't, although a subgroup do, have clear evidence of nerve injury to justify the diagnosis of neuropathic pain.

So it means that we've been searching for what is the mechanistic diagnosis. So it's been useful to have this new term, nociplastic pain – pain associated with sensitisation or windup as it can be called in the nervous system. So this is a patient who may have had some motor vehicle crash let's say, for example. The physical damage of that has healed so that nociceptive component has resolved. They haven't had a specific nerve injury and yet they have ongoing pain.

And the reason that we think that is the case is because of windup, particularly at brain level, perhaps also at spinal cord level in the nervous system. So that's nociplastic pain and the therapeutic target in that situation is working with them to help them to wind down or desensitise their pain system.

Whether or not one likes the term, I do think it's quite nice to have a different category. Because when the neuropathic pharmaceuticals came in, there was a heavy push towards labelling everything with a hint of nerve problem, you know, sciatic pain as being neuropathic and therefore assumed to be amenable to the nerve-modifying agents. But in fact, the push was probably greater than the evidence available for those interventions.

Yeah. So I think that was certainly true at the time and that has only become truer as the years have passed. From my perspective, I would say if you look at the effectiveness of pregabalin and gabapentin and so forth, in tightly diagnosed neuropathic pain that might meet enrollment criteria for randomised controlled trials, the number needed to treat at best would be four and often closer to 10. So meaning that you might need to be treating, in clinical practice, 10 patients with neuropathic pain before you get one patient who gets a 30% reduction in their neuropathic pain intensity. Read that these drugs can play a role, but it is not a dramatic role, generally speaking. And so to over-focus on some neuropathic component of the pain, that might be a little hard to define in clinical practice, which was perhaps where the pharmaceutical companies were nudging us in the early days, that can be a rabbit hole that we perhaps best not go down.

So looking at chronic pain management now in terms of managing it, first of all, we do have managing the biopsychosocial measures. Can you talk to us about that?

Yeah. I think it's a nice framework that encourages breadth of approach. Although there is still a risk, some commentators would say, in over-weighting the biological component and paying lip service to psychosocial. I guess this isn't limited to pain, it is evident in multiple aspects of medical practice, I think, that we can say that we are addressing psychosocial, but we're not doing it with any great optimism, or therapeutic determination, and we default back to biological treatments.

In our clinical practice where I work, we prefer a whole-person approach to pain. A bit easier to say and more lay-friendly language, but really we're talking about how much do we prioritise the different aspects in terms of diagnostic formulation and management approach. But I guess the underlying idea is that going broad, as we approach diagnostic formulation, and going broad in therapeutic approach is good.

Therapeutically recognising the risk that, if we over-focus on the biomedical, that may distract ourselves as the doctor, and it may also distract the patient from the active lifestyle management strategies that’re really where the greater evidence lies for pain reduction over time.

Certainly the Therapeutic Guidelines talks about social connection and GPs working on that with the person with the pain, and then psychological techniques, which a lot of clinicians use in their office and certainly referring to counselling as well. But even active listening and managing expectations. And then physical activity, which is always useful for pain as long as people don't overdo it. So they talk about pacing and activity scheduling.

Moving then to the analgesics for chronic pain and here we're talking about non-cancer pain. So the role of opioids has shifted subtly over the years. I'm wondering where we're at now with opioids for chronic non-cancer pain.

One of the lines that we have taken after much consideration with the Therapeutic Guidelines Working Group is to put forward the view that opioids, and analgesics in general in fact, are not first-line treatments for chronic non-cancer pain. I think that's a good solid statement. And really it leads on to the broader psychosocial, physical, nutritional aspects that you were mentioning before. I see in this that we're wanting to empower the GP to use strategies that they're very familiar with anyway. The psychological techniques, the physical strength training, the nutritional aspects, and so forth.

So I think in saying that analgesics and opioids are not first-line treatments, but prioritises them behind the psychology, the active listening, the expectation management, the physical strength training, pacing, nutritional advice, and so forth. Because I think as a society, there's been too much expectation that analgesics and opioids in particular would have a beneficial role.

We've said that analgesics can be considered if the patient is lacking sufficient engagement with social, psychological and physical management strategies. And then we focus in a little bit more on discussions of coming up with some sort of contract with the patient, about what medication might be worth trying, or not, expected benefits and harms. And importantly, I think duration of therapy. In the main we're framing it from the Therapeutic Guidelines that, in chronic non-cancer pain, we're trying to avoid setting up the expectation that you might be on this medication for the rest of your life. We're much more encouraging of the view that this could be a trial of the medication for a month, or two or three perhaps, with a view to facilitating your engagement with the active treatment approaches, with a view to tapering and ceasing or deprescribing those analgesics.

For that population group who is on it for more than two or three months, perhaps even up to years, what sort of evidence is there for opioids relieving that pain?

I would say very little to none. Most of our evidence, which has been a growing evidence base, says that opioids in long-term use are more likely to deliver harms than benefits. But there have been a number of studies looking at long-term use that say that opioids can be safely weaned and ceased without worsening. And often with a degree of benefit to someone's pain intensity. So the literature has really consolidated.

We do have one randomised controlled trial, the SPACE trial as it's called from 2018 in the States, Erin Krebs and colleagues, where it was a randomised trial, but non-blinded. Where they treated one group with opioids and the other with non-opioid analgesics and found that the non-opioid group did better in terms of pain intensity and better in terms of side effects. So that was the first long-term randomised trial.

Interesting. Yeah. Thank you. So Chris Hayes, you mentioned deprescribing earlier. Certainly it's a difficult situation. We inherit a patient from perhaps another GP, or another practice they move. And they have been on opioids for a long period of time. And we know theoretically, our task is to safely reduce that dose and convince the patient to reduce that dose. What help can we find there inside the Therapeutic Guidelines?

We did have substantial and animated discussion about this in our Therapeutic Guidelines Working Group. And we have put what I think is reasonably well balanced, at least expert opinion about how to deprescribe. This isn't hugely evidence-based in terms of the precise technique that one might use. And I don't know that the precise technique matters. But we did flag in the guidelines that a standard approach to deprescribing for chronic non-cancer pain would be to take a step down each month, if they've been on the medication for some years.

You can go faster than that and take a weekly step down if the patient has been on the medication for say less than three months and progress until complete cessation. And then the trick here is to give the patient a certain amount of voice, but not an overriding voice in terms of whether the deprescribe happens or not. So we say to patients, ‘We want your input into when that dose reduction might start and into the speed of reduction. Would you like a faster or a slower reduction? Or to come down in bigger or slower steps."

But this all amounts to: have a conversation about deprescribing, the standard approach is this – come down by 10 or 25% of the starting dose each month to achieve cessation, and that standard approach can be moderated in one way or another according to the patient response. And we have made some similar statements about deprescribing other analgesic agents, such as the gabapentinoids, NSAIDs etc.

Do the other agents require that sort of tapering? Do you get that rebound effect, if you stop them immediately?

Perhaps with the gabapentinoids, although this is variably reported in the literature. But we have suggested in the Therapeutic Guidelines that if someone has been on gabapentinoids for some time, that you probably don't lose anything by doing that staged step down. And you could step down somewhere between each week at the fast end, or every four weeks at the slower end. Partly using that staged reduction in chronic pain, we’re dealing with the psychology of the patient as well, or as much as the pharmacological, physiological aspects of that. So it is creating spaces. You come down slowly for the patient to get used to the idea and hopefully to engage with a more active self-management treatment approach.

Chris Hayes, thank you very much for that. There is more content that has been updated in the Therapeutic Guidelines, including cancer pain, chronic regional pain syndrome, shingles, the inhaled analgesics, but we won't have time to cover them in this podcast. So thanks very much for talking to us today.

That's a pleasure Justin.

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My guests’ views are their own and don’t represent Australian Prescriber, and my views are certainly all mine.